In this statement, AHRQ Director Carolyn Clancy reviews the work of the Agency for Healthcare Research and Quality and other health care entities to build support for research and improvements in patient safety.

Meeting/Conference > Meeting/Conference Proceedings

This summarizes a multidisciplinary conference (November 30 and December 1, 2000) dedicated to developing a research agenda in ambulatory patient safety. It reviews current knowledge about patient safety and contains information from presentations and discussions of conference participants. Eleven consensus recommendations are provided. The project was supported by grant number R13 HS10106 from the Agency for Healthcare Research and Quality (AHRQ).

Most evidence reports are placed on shelves and gather dust. This one, which reviewed the state of the evidence behind nearly 80 different safety practices (including computerized order entry, use of pharmacists on rounds, methods to prevent falls and nosocomial infections, and interventions to create a culture of safety), became quite influential, in part because it was the first effort to subject safety practices to the same scrutiny as other clinical practices in terms of their evidence of effectiveness. Nearly 100,000 copies of the report have been obtained from the Agency for Healthcare Research and Quality, and its now-famous list of the top 11 practices became the focus of many a new patient safety program at hospitals around the nation. The report served as one of the intellectual underpinnings of subsequent rankings of practices such as those by the National Quality Forum and the Leapfrog Group. It also engendered a spirited debate between those who advocated a practical approach to the adoption of safety practices and those promoting a more evidence-based approach. Readers are cautioned that evidence reports have limited shelf-lives, and it is worth reviewing recent literature before adopting even the most highly rated practices in this report.

This AHRQ-funded study illustrates potentially harmful drug-drug and drug-disease combinations that occur in ambulatory care in the elderly population. Solutions are provided for minimizing the opportunities for harm associated with these combinations.

This project studied the epidemiologic viability of using an injury surveillance system to track outpatient adverse drug events (ADEs) treated in hospital emergency departments. The authors found that the system could play a useful role in helping to understand outpatient ADEs, identifying areas for research, and monitoring ADE prevention.

Journal Article > Study

This AHRQ–funded study retrospectively examined the failure rate of recommended laboratory surveillance for patients on specific chronic medications. Using claims data from two large health plans, the investigators selected 11 drugs and their recommended lab testing intervals to capture and analyze data. Results suggested that nearly half of those requiring a chronic medication were subject to a potential laboratory monitoring error per year. Discussion includes detailed presentation of the potential error rates and how they differed among specific drugs and lab tests. The authors conclude that the prevalence of inadequate laboratory monitoring should stimulate further research about its impact on several clinical outcomes.

Book/Report

With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.

The Agency for Healthcare Research and Quality (AHRQ) hosted the 2005 Annual Patient Safety and Health Information Technology Conference. Transcripts and slide presentations are available from the five-day event.

Journal Article > Study

This AHRQ–funded study estimates the national prevalence of adverse drug events by capturing data from outpatient physician visits. Using survey data, investigators report on more than 4 million office visits associated with a diagnostic code for an adverse drug event. Although upward trends over time were not statistically significant, the authors conclude that their findings and methods may offer a mechanism for continued tracking of this important safety concern on a national level.

This AHRQ-funded retrospective study of 5473 patient encounters found that reviewing electronic pharmacy records could help identify preventable medication errors (particularly the use of contraindicated medications) in HIV-infected outpatients.

Tools/Toolkit > Database/Directory

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data to inform improvement. This Web site provides access to four modules of indicators: prevention, inpatient, pediatric, and patient safety.

Journal Article > Study

In this AHRQ-funded study, the investigators sought to increase acceptance of alerts by devising specific decision support for the ambulatory care setting, with only critical alerts interrupting clinician workflow.

The authors reviewed the literature on health information technology (HIT). They conclude that HIT may reduce pediatric medication errors, have the potential to improve safety and quality, and require more study to fully articulate the cost and implementation issues.

Journal Article > Study

The incidence of adverse drug events (ADEs) among children has been well characterized in hospital inpatients, but less studied in the outpatient setting. Conducted at six pediatric outpatient practices, this AHRQ-funded prospective cohort study evaluated the frequency of medication errors via chart review, review of prescriptions, and patient surveys. The overall rate of preventable ADEs was similar to a prior outpatient study, but nearly three-quarters of events were attributable to errors in administering drugs by the parents. Parents also did not consistently inform clinicians of ameliorable ADEs when they occurred, leading the authors to conclude that communication between clinicians and parents around the issue of medication side effects must be improved.